1. Field of the Invention
The present invention relates to systems and methods for managing requests for medical transportation.
2. Description of the Related Art
Requests for medical transportation, such as ambulance transportation, are typically handled by agents at a call center who determine the type of service required, an appropriate transportation provider to handle the request, and an assignment of liability for the cost of transportation. These decisions require consideration of a wide range of factors.
Each request for medical transportation involves the interests of many different stakeholders. The patient requires transportation that addresses his medical needs in a timely manner, and for which the cost is preferably born by the patient's insurer. Depending on the circumstances, the transportation request may be made by a patient or by attending medical personnel such as a nurse or physician. In such a case the medical personnel may require transportation to be provided in accordance with their assessment of the patient's needs, and in a manner that minimizes the costs born by the entity that employs them.
The patient's insurer has an interest in ensuring that transportation is provided in the most cost effective manner, and is provided in accordance with its obligations to the patient. The patient's insurer may also have agreements in place with one or more transportation providers governing the circumstances under which that provider will be used, mandating aspects of transportation such as response time, and the governing manner in which the cost of transportation is determined under various scenarios (e.g. fixed fee vs. at cost). The transportation provider has an interest in handling only those requests for which costs can be recovered.
Various governmental bodies at the local, regional and national levels are also stakeholders. These bodies have interests in protecting the populace at large, which is achieved through regulations that mandate minimum levels of service under various transportation scenarios. Where a governmental body is also the insurer of the patient (as in the case of Medicare coverage), further regulations may govern authorized services and cost and billing arrangements.
While the aforementioned stakeholders (patient, physician/nurse, insurer, transportation provider) are typically distinct entities, in some instances certain stakeholders may be affiliated with other related parties. For example, an insurer may own a facility to which a patient is to be transported to or from, in which case a distinct set of operating rules may apply. A transportation provider may likewise own, be owned by, be jointly owned with, or contract with a call center operator.
Therefore, while it is desirable to utilize a call center to receive and dispatch requests for medical transportation, the agents staffing the call center must be aware of and able to apply all of the contractual and regulatory provisions that are relevant to the circumstances of each request in order to accurately determine patient eligibility for the requested transportation, an appropriate level of service and response time, liability for the cost of transportation, and an appropriate transportation provider. However, due to the many considerations involved in these decisions, the conventional call center agent is typically provided with only a limited set of standard questions to ask every caller, and is trained to determine only an appropriate level of service based on the answers to those questions, or in some instances to determine a level of service and response time, and to assess financial responsibility for the transportation. Even with this reduction of complexity, agent training is difficult and time consuming, and the agent's decisions are prone to error. Further, it is likely that an agent who is in doubt as to the appropriate level of service will opt for the higher of two possible levels of service, sometimes leading to unnecessary over-utilization of scarce and costly resources. These problems are compounded where the requests handled by the agent may originate from different localities governed by different regulations, or may involve the patients of a number of different health insurance providers, thus requiring the agent to apply different sets of rules depending on such factors.